PN 107 Final Exam Questions With Verified
And Updated Answers
A
Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for
physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing
medication is a patient's right and may be appropriate. The other incorrect options do not
feature violation of another's rights. - answer✔Which behavior best demonstrates aggression?
a. stomping away from the nurses' station, going grabbing a tray from the meal cart
b. bursting into tears, leaving the community meeting, and sitting on a bed hugging on a bed
hugging a pillow
c. telling the primary nurse, "i felt angry when you said i could not have a second helping at
lunch."
d. telling the medication nurse, "i am not going to take that, or any other, medication you try to
give me."
C
Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher
risk for violence. The patient in the correct response has the greatest disruption of ability to
perceive reality accurately. People who feel persecuted may strike out against those believed to
be persecutors. The other patients have better reality-testing ability. - answer✔Which scenario
predicts the highest risk for directing violent behavior towards others?
a. major depression with delusions of worthlessness
b. obsessive-compulsive disorder; performed many rituals
c. paranoid delusions of being followed by alien monsters
d. completed alcohol withdrawal; beginning a rehabilitation program
ALL RIGHTS RESERVED.
D
Defining characteristics for risk for other-directed violence include a history of being abused as
a child, having committed other violent acts, and demonstrating poor impulse control. There is
no indicator that the patient will experience injury. Ineffective coping and impaired social
interaction have lower priorities. - answer✔A pt was arrested for breaking windows in the
home of former domestic partner. the pt's hx also reveals childhood abuse by a punitive parent,
torturing family pets, and an arrest for disorderly conduct. which nursing diagnosis has priority?
a. risk for injury
b. ineffective coping
c. impaired social interaction
d. risk for other-directed violence
D
Confused patients are not always able to evaluate the actions of others accurately. This patient
behaved as though provoked by the intrusive actions of the staff. - answer✔A confused older
adult patient in a skilled nursing facility was asleep when unlicensed assistive personal (UAP)
entered the room quietly and touched the bed to see if it was wet. the pt awakened and hit the
UAP in the face. which statement best explains the pt's action?
a. older adult pt's often demonstrate
exaggerations of behaviors used earlier in life
b. crowding in skilled nursing facilities increases an individual's tendency toward violence
c. the pt learned violent behavior by watching other pt's act out
d. the pt interpreted the UAP's behavior as potentially harmful
C
Intervention should begin with analysis of the patient and the situation. When anger is
escalating, a patient's ability to process decreases. It is important to speak to the patient slowly
and in short sentences, using a low and calm voice. Use open-ended statements designed to
hear the patient's feelings and concerns. This leads to the next step of planning an intervention.
- answer✔A pt is pacing the hall near the nurses' station, swearing loudly. an appropraite initial
intervention for the nurse would be to address the pt by name and say:
a. "what is going on?"
b. "please be quite and sit down in his chair immediately."
ALL RIGHTS RESERVED.
c. "i'd like to talk with you about how you're feeling right now."
d. "you must go to your room and try to get control of yourself."
A
Making sure space is present between the nurse and the patient avoids invading the patient's
personal space. Personal space needs increase when a patient feels anxious and threatened.
Allowing the patient to block the nurse's exit from the room may result in injury to the nurse.
Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until
further assessment suggests the patient's aggression is abating. One arm's length is inadequate
space. - answer✔A pt who was responding to auditory hallucinations earlier in the morning
now approaches the nurse shaking a fist and shouts, "back off!" and then goes to the day room.
while following the pt into the day room, the nurse should:
a. make sure there is adequate physical space between the nurse and pt
b. move into a position that places the pt close to the door
c. maintain one arm's- length distance from the pt
d. begin talking to the pt about appropriate behavior
B
A patient gains feelings of security if he or she sees others are present to help with control. The
nurse gives a simple direction, honestly states what is going to happen, and reassures the
patient that the intervention will be helpful. This positive approach assumes the patient can act
responsibly and will maintain control. Physical control measures are used only as a last resort. -
answer✔An intramuscular dose of antipsychotic medication needs to be administered to a pt
who is becoming increasingly more aggressive and refused to leave the dayroom. the nurse
should enter the say room:
a. and say, "would you like to come to your room and take some medication your health care
provider prescribed for you?"
b. accompanied by 3 staff members and say, "please come to your room so i can give you some
medication that will help you regain control."
c. and place the pt patient in a basket-hold and they say, "i am going to take you to your room
to give you an injection of medication to calm you."
d. accompanied by a male security guard and tell the pt, "come to your room willingly so i can
give you this medication, or the guard and i will take you there."
C
ALL RIGHTS RESERVED.
The desire for revenge signals an urgent need for professional supervision to work through
anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the
patient. The distracters are normal in a person who was assaulted. They usually are relieved
with crisis intervention, help the individual regain a sense of control, and make sense of the
event. - answer✔After an assault by a patient, a nurse has difficulty sleeping, startles easily, and
is preoccupied with the incident. The nurse said, "That patient should not be allowed to get
away with that behavior." Which response poses the greatest barrier to the nurse's ability to
provide therapeutic care?
a. startle reactions
b. difficulty sleeping
c. a wish for revenge
d. preoccupation with the incident
A
Intervention techniques are learned behaviors and must be practiced to be used in a smooth,
organized fashion. Every member of the intervention team should be assigned a specific task to
carry out before beginning the intervention. The other options are useless if the staff does not
know how to use physical techniques and how to apply them in an organized fashion. -
answer✔The staff development coordinator plans to teach use of physical management
techniques for use when patients become assaultive. Which topic should the coordinator
emphasize?
a. practice and teamwork
b. spontaneity and surprise
c. caution and superior size
d. diversion and physical outlets
B
The correct response indicates impaired circulation and necessitates the nurse's immediate
attention. The incorrect responses indicate the patient has continued aggressiveness and
agitation. - answer✔An adult patient assaulted another patient and was then restrained. One
hour later, which statement by the restrained patient requires the nurse's immediate
attention?
a. "i hate all of you."
b. "my fingers are tingly."
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